Medicine at the frontier

"Pashto Peak" as seen from the rooftop of our house

Sundays have become very important to me here, particularly Sunday afternoons. We officially have a six day work week, and though most Sundays I have to go into the hospital as well, it is usually only for a quick ward round or to assist with one or two emergency patients.

This means that Sundays give me some time to myself to read, to think and to write – very valuable moments to myself during what can be a hecti
c pace of life.

Most of these blogs you have been reading are conceptualised on quiet Sunday afternoons, often while sitting on the expansive flat roof of our house. The view is one of greenery and the slopes of the jagged mountain range that surrounds our town.

As a Capetonian far from home, it is a great comfort to me to be living in sight of a mountain again – yes, yes I know how we “Capies” like to go on about our famous mountain, but it really is beautiful to me and I miss it a great deal.

So, “Pashto Peak” as I have unofficially dubbed the closest part of the range (after the Pashto language which is predominantly spoken here), has become a favourite point of contemplation. This brings me to the challenges of providing medical care when you are twice removed from the patient by the barriers of language.

If my combined language abilities were to be somehow summed up on a cocktail menu, then I would be mixer of the following: A large portion of English Lager, a generous dash of Afrikaans “Mampoer” (this is a form of South African moonshine a little bit like schnapps but quite a lot stronger), a squirt of Xhosa Umqombothi (a traditionally home brewed beer) and a tiny drop of Spanish Sangria.

Now I have no idea how this would taste in reality, or what it might be called – “Lost in Translation” perhaps? – but so far it has served me pretty well in the working and social environments in which I have found myself.

Here in Pakistan, however, this cocktail is quite useless (not to mention the fact that  alcoholic drinks are forbidden, and mention of such is considered culturally insensitive…). I am totally reliant on translation in order to function effectively here, and it has re-emphasised for me the importance of good communication in healthcare settings.

The two senior staff with whom I work most closely in the clinical context both speak very good English, which is a good first step. But, neither of them is from this region, so their first language is Urdu rather than the locally spoken Pashto. But almost all the patients we see in the ER and IPD (inpatient department) speak only Pashto…and so we are stuck again!

Luckily, almost all the more junior nursing staff speak Pashto as their first language and Urdu as their second and so altogether, and with much patience (and not a little bit of frustration), we navigate patient interviews as follows: me to the senior nurse in English to junior nurse in Urdu to patient in Pashto.

The patient then contemplates a response and then: patient to junior nurse in Pashto, to senior nurse in Urdu, and back to me in English.

Phew!

During much of the sometimes lengthy discussions, I am silent and this has been an interesting experience in improving my ability to interpret facial expressions and body language (not always too accurately I’m afraid).

Exactly how much is lost in this tautological transfer of information is hard to say, but I am often surprised by the answers that eventually come back to me: either far too short, far too long or totally off the point altogether. Not to mention the frequent intrusions by family members of the patients who are very fond here of giving their version of the story which, once translated, not infrequently turns out to be rather different from the patient’s own version…sigh. And so, we start again with a re-phrased enquiry until finally, the necessary details start to become clear.

This slows things down a lot of course, but the staff and patients are very tolerant of my persistent questioning and somehow we manage to get it done.

Oh, how much easier things would be if we all just spoke the same language! Except of course that with language and culture being so closely linked, how much unique and valuable diversity would be lost as well?

In the end then, there is nothing for it but to push on through and keep sipping this new language cocktail, which is starting to taste better and better by the day.

Perhaps, by the end of my time here I will be able to add a sprinkle of spicy Urdu and Pashto to my own cocktail of languages and they might just be the secret ingredients which turn it into something truly delicious.

So, for now I will say: “Pa ma cha de cha” (travel well on the road ahead) until next time.

Many MSF projects are set up in response to emergencies: earthquakes, outbreaks of epidemic disease or the fallout from violent conflict for example. It is perhaps the classic image or perception of the organisation  – rushing “into the breach” to save the day.

This is of course a vital role and the speed and effectiveness of the response that MSF is consistently able to mount in these sorts of situations is one of the things which has helped build the reputation of the organisation internationally.

But emergencies aren’t the only time that MSF gets involved however. There are also many projects running worldwide that have a more long-term or stable character and deal with more persistent problems.

Twisted swollen hands, the painful legacy of a failing healthcare system

My work here in the Northwest Frontier Province falls into this category. While there always remains the threat of violent conflict in our region, or the possibility of a natural disaster (such as the earthquake which devastated areas of Kashmir in 2005, to which MSF responded with a high degree of success), the work I am doing here now is not addressing any acute emergency. Rather, the team I work with is attempting to prop up or fill the gaps in a national health system that is struggling to meet the needs of the population.
In this sort of “quietly” urgent situation, it is often those with chronic disease who suffer the most.

Everyday in the ER and MSF inpatient department, I am meeting people each treasuring a bundle, bag or folder filled with doctors letters, lab tests and x-ray reports, prescriptions and sick notes and referrals: cacophonies of paperwork which, due to a fundamental lack of integration, add up to little tattered piles of confusion. Misdiagnosis (sometimes radically), inappropriate treatment or no treatment at all, missed or absent follow-up and review, and often numerous and unnecessary over-investigation without benefit, is the norm.

Without doubt, there are centres of medical excellence in Pakistan where the highest standards are upheld but like in so many other places in the world, these are beyond the budget of the majority of people. As a result, a significant proportion of people suffer the burden of inadequate care.

We hear all this in the usually long and complicated stories our patients tell us about their ailments, and it is difficult to suppress the rising frustration and sadness at things being this way.

At the moment under our care is a woman essentially crippled by Rheumatoid Arthritis. Though this is a disease that is difficult to manage even under the best of circumstances, due to delays in her diagnosis and long and tragic gaps in her treatment, she is far more severely affected than she could have been had she received a consistent and appropriate level of care. Though she is only in her 40’s, even the most simple movement is an agony. Her hands are twisted and virtually useless and she requires full-time care from her family.

Talking with her, I am reminded how many others here are carrying similar burdens and that we are reaching such a small proportion of those who could use our help.

Accepting this limitation is a daily challenge but at least with time and care we will help this one person; and then perhaps tomorrow another, and another after that. One day at a time until we can do more.

Being far away from home isn’t easy. While life on mission has many rewards – not least the chance to go places and see things that few others will experience – it implies time away from family and friends.
This means missing things like birthdays, important gatherings, births and, sometimes, even deaths amongst those close to us.

me and the team on my birthday, from back left of picture: Miki (Japanese midwife), Lynette (Philipino surgeon), Rachel (Kenyan Nurse/Midwife), Margarita (Philipino Anaesthetist) front from left: Ben (Belgian Field Co-ordinator), Me, David (German logistician)

The support we would usually have is absent and so, to help us get through the difficult days, it is the team of MSF colleagues which becomes a surrogate family.

This doesn’t mean that team dynamics are always easy. After a tough day there is no doubt that we can sometimes get on each other’s nerves. Most often though, after similarly tough days, it is the support of the other expats that has helped me get by.

This doesn’t usually come through in the form of grand gestures. Although, when one of the others returns from a weekend off in the capital with real cheese or similar rare delicacies it does A LOT to lift the spirits.
Instead, it is the simple things like having someone to talk with about a difficult case or being surprised with freshly baked cookies to enjoy at teatime, that make all the difference.

Specifically, I want to thank my team for making my recent birthday an unexpectedly enjoyable one.
I woke up on the morning I turned 32 feeling very nauseous – not a good start! What would later turn out to be a bout of dysentery, got progressively worse and I spent most of the day feeling pretty rotten. But in the evening I was surprised with a proper party including balloons (one of which was fashioned into a spectacular headdress just for me), cake and even birthday presents!

The dysentery has thankfully been resolved and time has moved on, but I will always remember my Pakistani birthday – for the place where I celebrated it, but more importantly for the people with whom I spent it.
MSF is an organisation made great by the great people who make it tick. I feel very privileged to share my time here with some of them. THANKS TEAM, YOU GUYS ROCK!